NUR 131 Exam 4

a) does not follow the tenets of a specific faith

The nurses notes on the admission form that the patient has indication "no religious preference." What does this indicate to the nurse about the patient?
a) does not follow the tenets of a specific faith
b) is in denial about his religious beliefs
c) does

d) hold her hand, sit with her, & listen

Your pt is a 17 year old who lost her right lef in a MVA. After her parents leave, she asks you, "Why did God let this happen to me? I have always followed his commandments." Which action best depicts the "caring" aspect of SENC?
a) "Let me call your pare

d) perceived

The student nurse has earned A's in all of her prerequisite courses. For the first exam in a nursing course, she earns a D and now feels that she may not be smart enough to become a nurse. What type of "loss" is the student experiencing?
a) actual
b) exte

d) "Tell me how you are feeling right now

Your 55 year old pt was just informed that she has metastatic pancreatic cancer and has 4 months to live. After the provider leaves, she says to you, "I don't want my family to know. But they have to know. Please don't tell them. Please tell me what to do

a) "You sound very upset. Tell me more about your dad.

The pt is dying of cancer and can no longer swallow. the son states to the nurse, "You MUST give dad some water, he always drank a lot of water." The nurse's best response is
a) "You sound very upset. Tell me more about your dad."
b) "Your father is dying

d) this is an example of distress & could affect the pt's health status

The hospitalized pt states, "I need to know when I'm going to be discharged. I'm so upset & worried that I'm missing work." The nurse knows:
a) this is an example of "eustress" & no intervention is necessary
b) this is an example of psychological stress &

a) true
Tenormin is a beta-blocker (or otherwise a anti-hypertensive medication)

A pt who is taking atenolol (Tenormin) may not exhibit a rise in blood pressure & pulse during the alarm stage of the general adaptation syndrome
a) true
b) false

c) the occurrence of stress in pts is unpredictable

The nurse should assess every pt to determine if stress reduction interventions should be part of the plan of care. The rationale for this action is that:
a) there are more persons experiencing mental illness now than in the past
b) life is so much more s

c) close the blinds, dim the lights, and ask the pt what other measures would help him rest

Mr. Arbor complains to the nurse that he is feeling anxious. He states, "I'm just so tired of all these tests they are doing, and it's so noisy here at night." Mr. Arbor's pulse is 110 bpm and his blood pressure is 140/70 mmHg. Nursing actions should incl

a) true
GCS correlates to the patient's ability to function. The lower the score, the more nursing intervention required.

For any patient with an altered level of consciousness, the Glasgow Coma Scale score will help the nurse in planning care.
a) true
b) false

a) investigate why
It's important to understand why the pt hasn't been adhering to the scheduled med schedule
Issues like vision, literacy, & side effects could be easily rectified if investigated

When conducting a weekly home visit with an older pt, the nurse realized the pt has not been adhering to his recommended medication schedule. What should the nurse do next?
a) investigate why
b) reprimand the pt for being noncompliant and explain how impo

c) maintaining the child's home sleep routine

A 4 year old patient resists going to sleep. To assist this pt, the best action to take would be:
a) adding a daytime nap
b) allowing the child to sleep longer in the morning
c) maintaining the child's home sleep routine
d) offering the child a bedtime sn

d) sleep apnea

During rounds on the night shift, you note that a pt stops breathing for 1-2 minutes several times during the shift. This condition is known as:
a) cataplexy
b) insomnia
c) narcolepsy
d) sleep apnea

a) amount drained

What is missing from the documentation regarding the emptying of draining from a wound?
"03/12/16 07:50: Hemovac drained serosanguinous fluid over 12 hours. No odor or perulent material noted at drainage site."
a) amount drained
b) AM or PM
c) description

b) increase protein foods in the diet

The nurse is working with a patient with low total protein & serum albumin levels. The patient presents with bilateral pitting lower extremity edema. Which education should the nurse provide to decrease and prevent edema formation?
a) increase cholesterol

b) dehiscence involves the protrusion of internal viscera from the incision site; with evisceration, there is a separation of one or more layers of wound tissue

A student nurse asks the nurse the difference between dehiscence & evisceration. Which would be the best explanation?
a) dehiscence is an urgent complication that requires surgery ASAP; evisceration is not as urgent
b) dehiscence involves the protrusion o

a) infection at the incisional site

3 days after abdominal surgery, the nurse notes a 2cm area of erythema & swelling at the proximal end of the incision. The area is tender & warm to the touch. Staples are in tact along the incision, no obvious drainage. Temp 100.8 F. The nurse suspects:
a

to prevent cutting off circulation

The nurse avoid placing a dressing that wraps around an extremity to prevent what complication?

to prevent cross-contamination of infection in other areas of the wound

The nurse irrigates top to bottom to prevent what complication?

to promote blood flow

Why should the nurse prevent packing the gauze tightly into the wound?

- determine funeral plans when ready for that conversation
- determine if pt has advanced directives

What assessments can you make for a dying patient?

- caregiver role strain
- risk for grieving

What nursing diagnoses could be used for someone experiencing loss, death, or grief?

- have family help with care (if possible)
- encourage questions
- encourage visit to the chapel or to talk with clergy
- explore coping mechanisms
- provide anticipatory guidance
- acknowledge & validate feelings of the pt & family
- remind family member

As a nurse, how can you support your patient's loved ones when the patient is terminally ill?

hospice care

- holistic care for dying patients
- HCP must certify that patient will die within 6 months

1. The quality of life is just as important as the length of life
2. Those who are terminally ill should be allowed to face death with dignity & surrounded by the comfort of their families & homes

What are the 2 key premises for hospice care?

palliative care

- holistic comfort care
- no further efforts will be made to stop the disease process or prevent the patient from dying

spirituality

- a "journey" that takes place over time & involves the accumulation of life experiences & understanding
- an attempt to find value, meaning, & purpose in life

true
spirituality is important regardless of religion

True/False: Spirituality is important regardless of religion

1. Denial
2. Anger
3. Bargaining
4. Depression
5. Acceptance

What are the 5 Kubler-Ross stages of loss?

loss

the undesired change or removal of a valued object, person, or situation

- actual
- perceived
- physical
- psychological
- external
- environmental
- loss of significant relationship
- maturational
- situational

What are the different types of loss?

perceived loss

- internal & only identified by the person experiencing it
- less obvious to the person experiencing it

maturational loss

- occurs during the life cycle predictably
- loss of aspect of self, resulting from normal changes of growth & development

situational loss

loss of a person, thing, or quality resulting from an alteration of a life situation involving changes r/t death, illness, change in body image, & environment

- physical
- emotional
- cognitive
- behavioral

What are the four reactions to loss?

physical loss

type of loss characterized by chest tightness, breathlessness, fatigue, lack of energy, & appetite change

emotional loss

type of loss characterized by numbness, loneliness, sadness, guilt, shock, & anger

cognitive loss

type of loss characterized by forgetfulness, inability to exercise, & disorganization

behavioral loss

type of loss characterized by arguing, insomnia, withdrawal, & irritability

H - sources of hope
O - organized religion
P - personal spirituality/practices
E - effects on medical care & end-of-life issues

What does the acronym HOPE stand for in relation to spirituality?

SP - spiritual/religious belief system
I - integration within a special community
R - ritualized practices & restrictions
I - implication for medical care
T - terminal events planning

What does the acronym SPIRIT stand for in relation to spirituality?

faith

- evolving pattern of believing that grounds & guides/helps us make sense of the world & confront the challenges we face
- represents a set of beliefs

hope

- dynamic process that reflects a positive orientation toward future outcomes
- positive expectation & desire for future things to happen

- date/time you noticed absence of respirations & pulse
- any equipment present (i.e. ventilator)
- disposition of patient's belongings
- when body was transported to the morgue

What documentation is the nurse responsible for after death of a patient?

- openness to discussing end-of-life care options
- extraordinary measures
- life support
- DNR/DNI orders

What are some cultural considerations that we need to think about surrounding end of life care?

b) 4

How many stages of death are there?
a) 2
b) 4
c) 6
d) 8

1-3 months prior to death

stage of death where the patient begins to withdrawal from world/people; increased sleep and decreased appetite

1-2 weeks prior to death

stage of death that shows a host of physical changes that indicate the body is about to lose itself

days to hours prior to death

stage of death that brings a o surge of energy; brings desire to eat & socialize; may become agitated and/or dehydrated

moments prior to death

stage of death
dying person doesn't respond to touch/sound & can't be awakened

post-mortem care

caring for the patient's body after death

DNR (do not resuscitate)

an order written by a physician to not attempt resuscitation when cardiac or respiratory arrest occurs

AND (allow natural death)

Instead of writing a DNR order, some physicians may prefer to to write a/an _________ order, since it makes the patient's intentions more clear.

grief

physical, psychological, & spiritual responses to a loss (emotional response to loss)

- uncomplicated
- complicated
- anticipatory
- disenfranchised

What are the 4 types of grief?

anticipatory grief

grief that is experienced before the loss occurs; cognitive, affective, cultural, & social reactions

mourning

action associated with grief; outward expression of loss
1st task - accept reality
2nd task - work through pain
3rd pain - emotionally relocate dead

bereavement

mourning & adjustment time following a loss; form of grief with anxious feelings (insomnia, hyperactivity)

- age
- health status
- cognitive status
- relationship with deceased
- significance of the loss
- support system
- unresolved conflict
- circumstances of the loss
- previous exp with loss
- spiritual/cultural beliefs & practices
- timeliness of death
- d

What are some factors that affect grief?

Adaptation

- possible/desired outcome of stress; involves adjusting to the stress/stressor
- outcome depends on the balance btwn the strength of the stressors & the effectiveness of the person's coping mechanisms

Coping

dynamic cognitive & behavioral efforts to manage demands (external/internal) that are appraised as exceeding resources

stress

- any disturbance in a person's normal balanced state; unique response by each person to a stressor
- state of mental/emotional strain or tension

- distress
- eustress
- developmental
- situational
- time
- anticipatory
- physiological
- psychological

What are the different categories of stress?

distress

type of stress that can threaten health

eustress

good stress

developmental stress

type of stress associated with life stages; predicted to occur at various times in life

situational stress

type of stress that is random & unpredictable

time stress

type of stress that happens when a person is unable to meet demands

anticipatory stress

stress about the future; can also be stress about something vague or undefined

physiological stress

type of stress that affects the body

psychological stress

type of stress that arises from a life event

stressor

stimulant that the person perceives as a challenge or threat

- alter the stressor
- adapt to the stressor
- avoid the stressor

What are the 3 common approaches to coping with stress?

- personal perception of the stressor
- overall health status
- support health
- hardiness
- age
- developmental level
- life experiences

What are some personal factors that influence adaptation?

general adaptation syndrome (GAS)

- Selye's theoretical model of the physiological responses to stress
- nonspecific bodily responses shared by all people
- response to distress & eustress

3 stages

How many stages are there in general adaptation syndrome (GAS)?

- initial alarm stage
- resistance
- recovery OR exhaustion

Name the 3 stages of the general adaptation syndrome (GAS)

initial alarm stage

stage of general adaptation syndrome that has two stages: shock & countershock

shock

begins when cerebral cortex 1st perceives a stressor & send out messages to activate the endocrine & sympathetic nervous systems

countershock

all changes are reversed & person becomes less able to deal with the immediate threat

Resistance

- stage of the general adaptation syndrome (GAS)
- maintenance of homeostasis is the goal; involves use of coping mechanisms
- body attempts to cope & protect itself from the stressor

homeostasis

internal & external equilibrium

Recovery

if adaptation was successful

Exhaustion

if adaptive mechanisms become ineffective/nonexistent; decreases BP, elevates HR & RR

Fight or flight

- how the body responds to stress; activates the ANS
- increases HR, BP, RR, dilates pupils, decreases peristalsis

Defense mechanisms

automatic reaction of the body against disease-causing organisms; protective coping mechanisms

prevent harm

Short-term defense mechanisms prevents _______ from stressors

prevents healthy growing

Long-term defense mechanisms prevent _____________

- denial
- rationalization
- projection

Name three of the ego defense mechanisms

Stress-induced organic responses

- continual stress, result of repeated CNS stimulation & elevation of certain hormones
- repeated CNS stimulation
- elevated of certain hormones
- results in long-term changes in body systems

- hypochondriasis
- somatization
- somatoform pain disorder
- malingering

Name the four somatoform disorders

hypochondriasis

somatoform disorder where the person is preoccupied with the idea they'll become seriously ill; abnormally concerned with their health & manifests physical symptoms

Somatization

somatoform disorder where anxiety & emotional turmoil are expressed in physical symptoms, loss of physical function, pain that changes location often, & depression

somatoform pain disorder

somatoform disorder where emotional pain manifests physically

Malingering

somatoform disorder that's different from the other disorders bc it's a conscious effect

- crisis
- burnout
- PTSD

Name the three stress-induced psychological responses

crisis

- exist when an event in a person's life drastically changes the person's routine & they perceive it as a threat to self
- usual coping methods are ineffective, resulting in increased levels of anxiety & inability to function

burnout

occurs when unable to cope effectively without the physical & emotional demands

PTSD (post-traumatic stress disorder)

specific response to a violent, traumatizing event

Stress appraisal

automatic, often unconscious assessment of stressor

Stress management

- reduces strength & duration of the stressor
- relieves or remove responses to stress
- uses effective coping mechanisms

Anxiolytics

- anti-anxiety agent
- used for management of various forms of anxiety, including generalized anxiety disorder (GAD)
- some more suitable for short-term use while others are more long-term

- benzodiazepines
- sedatives-hypnotics
- non-benzodiazepines
- antihistamines

Name some classes of anxiolytic drugs

sedatives-hypnotics

- used to provide sedation, usually prior to procedures
- also used to manage insomnia, as an anticonvulsant, muscle relaxant, adjunct in management of alcohol withdrawal syndrome, anesthesia, or as an amnestic

Antihistamines

- relieve symptoms associated with allergies, includes rhinitis, urticarial, & angioedema
- used as adjunctive therapy for anaphylactic reaction
- may be used to treat motion sickness, insomnia, Parkinson-like reactions, & other non-allergic reactions.

make healthy choices that reduce the negative effects of stress

What can a person do to effectively cope and balance stress?

Anxiety

vague, uneasy feeling of discomfort or dread accompanied by an automatic response; a feeling of apprehension caused

Fear

emotion or feeling of apprehension/dread from an identified danger, threat, or pain

Anger

strong, uncomfortable feeling of animosity, hostility, extreme indignation, or displeasure

Crisis

- exists when an event in a person's life drastically changes the person's routine & they perceive it as a threat to self
- usual coping methods are ineffective, resulting in increased levels of anxiety & inability to function

Homeostasis

internal & external equilibrium

communication enhancement, ear care, nutrition management

What outcomes could the nurse plan for a sensory deficit?

cognitive stimulation, reality orientation

What outcomes could the nurse plan for with acute confusion?

anxiety reduction

What outcomes could the nurse plan for with chronic confusion?

memory training, neurological monitoring

What outcomes could the nurse plan for with impaired memory?

self-care assistance

What outcomes could the nurse plan for with unilateral neglect?

- assess med hx.
- assess vision
- see if the pt has a hearing aid (and check batteries)
- check for nerve damage
- assess hx. of CVA
- assess gait & motor skills
- check for bed sores
- assess GCS

What assessments could you make for a patient with a sensory alteration or mobility impairment?

- use picture cards
- limit environmental stimuli
- use light stimuli/touch
- glasses (clean, within reach)
- provide sufficient lighting
- check hearing aid

What care can you implement for a patient with a sensory alteration or mobility impairment?

Sensory deficits
deficit in normal function of sensory reception/perception

deficit that may stem from impaired reception, perception, or both

- developmental level
- culture
- illness and medications
- stress
- personality & lifestyle

What are some factors for sensory alterations?

- flexion
- extension
- hyperextension
- lateral flexion
- internal rotation
- abduction
- adduction
- circumduction
- external rotation

What are some ways that you can assess ROM for different joints on a patient?

Mobility

body movement

Immobility

inability to move the body or a specific part

- mental status
- mobility
- ROM

What are some mobility developmental differences that happen through the lifespan?

gustatory sense; nutritional deficits

Patient with an impaired __________ sense may eat less & be at risk for ________ deficits

Stimulus

sight, sound, taste, touch, pain

Reception

process of receiving stimuli from nerve endings

Perception

interpreting the impulses transmitted from the receptors & giving meaning to the stimuli

I. olfactory nerve

sensory nerve; sense of smell

II. optic nerve

sensory nerve; visual activity, fields of vision, & ocular fundi

III. oculomotor

motor nerve; extraocular movement (EOM) & pupillary contraction

IV. trochlear

motor nerve; extraocular movement (EOM)

V. trigeminal

sensory & motor nerves; corneal reflex, reflexes of the scalp & teeth, facial sensations, jaw movement

VI. abducens

motor nerve; extraocular movement (EOM)

VII. facial

motor & sensory nerves; facial movement, sense of taste

VIII. auditory

sensory nerve; hearing & equilibrium

IX. glossopharyngeal

motor & sensory nerves; swallowing, gag reflex, tongue movement, taste, secretion of saliva

X. vagus

motor & sensory nerves; sensation of pharynx & larynx, motor activity of swallowing & vocal cords, peristalsis, digestive secretions; sensations in the cardiac, respiratory, & blood pressure reflexes

XI. spinal accessory

motor nerve; head movement & shoulder elevation, motor to the larynx for speaking

XII. hypoglossal

motor nerve; tongue movement

I Olfactory
II Optic
III Oculomotor
IV Trochlear
V Trigeminal
VI Abducens
VII Facial
VIII Vestibulocochlear
IX Glossopharyngeal
X Vagus
XI Accessory
XII Hypoglossal

What are the 12 cranial nerves?

range of movement (ROM)

maximum movement of a joint

- activity intolerance
- disuse syndrome, risk for
- falls, risk for
- injury, risk for
- mobility: bed, impaired
- mobility: physical, impaired
- mobility: wheelchair, impaired
- sedentary lifestyle

What are some nursing diagnoses you could make for a patient with a sensory alteration or mobility impairment?

activity intolerance

state in which a pt has insufficient physical or psychological energy to carry out daily activities

Disuse syndrome, risk for

exists when a pt's prescribed or unavoidable inactivity creates the risk for deterioration of other body systems

Mobility: physical, impaired

limitation of independent, purposeful body movement

Sedentary lifestyle

habit of life that's characterized by a decreased physical level

Footdrop

foot appears floppy with toes pointed down

Gait

a person's manner of walking; style, balance, posture, safety

Hemiparesis

slight weakness in a muscle/extremity

Hemiplegia

paralysis of our side of the body

Joint contracture

- chronic loss of joint mobility caused by structural changes in non-body tissues
- leads to shortening & hardening of the joints, causing joint deformities
- develops when joint aren't moved periodically

Muscle atrophy

decrease in the size of muscle tissue due to lack of use or innervation; weakness

Aphasia

loss of ability to understand/express speech

Ototoxic

having a toxic effect to the ear or its nerve supply

20%
2 billion

By 2050, older adults will be _______% of the population, which is estimated to reach ___ billion people age 60+

- fall
- gait
- potential signs of harm/abuse
- dehydration
- nutrition
- sleep
- ADLs
- cognitive status
- support system
- social network

What assessments can you make for an older adult?

- fall risk precautions
- independence
- cognitive function
- illness prevention
- communication
- caregiver support

What outcomes can you implement for an older adult?

- ensure pt is close to nurses station
- wear fall bracelet
- bed low with locked wheels
- bed alarm
- non-skid socks
- keep door open

What outcomes can you implement for a patient who is a fall risk?

- caregiver role strain, risk for
- falls, risk for
- health maintenance, ineffective
- memory, impaired
- injury, risk for
- coping, ineffective
- knowledge, deficient (specific)
- nutrition, imbalanced: more than body requirements
- nutrition, imbalance

What are some nursing diagnoses you can use for an older adult?

memory, impaired

nursing diagnosis used for dementia patients, primarily Alzheimer's disease

S - skin integrity
P - problems eating / pain
I - incontinence
C - confusion
E - evidence of falls
S - sleep disturbance

What does the acronym SPICES stand for?

Hendrich II fall risk model

- eight-factor assessment model
- score of 5+ indicates a high fall risk; 1 point assigned for each thing the pt meets
- get up & go test

Katz index of independence

- determines pt's level of independence with performing ADLs
- score of 6+ is high (independent); 1 point assigned for each category the pt can do independently

mini cog

screening tool that detects cognitive impairments in adults

Polypharmacy

use of multiple medications

- Risk factor for acute confusion, delirium, & depression
- Older adults are at a greater risk for adverse drug reactions
- Higher potential of drug-drug interactions
- May lead to decreased medication compliance, poor quality of life, & unnecessary drug

What are some risks of polypharmacy?

- retirement communities
- continuing care retirement communities
- assisted living facilities
- nursing homes
- aging in place
- age-friendly residences
- age-friendly communities
- naturally occurring retirement communities

What are some living arrangements for older adults?

patient safety goals

- Determined by The Joint Commission
- Focuses on significant problems in health care (safety) & specific actions to prevent them based off of current evidence based practice

Mini-mental state examination (MMSE)
0-12: severe dementia
13-20: moderate dementia
21-24: mild dementia
25-30: normal cognitive function

- test used to measure cognitive ability
- 1 point for each answer correct in each category; maximum score is 30

- biological
- psychological
- spiritual
- social
- sexual

What are the 5 (categories of) concepts of aging?

- wear & tear theory
- genetic theories
- cellular malfunction
- autoimmune reaction
- stochastic

What are the biological concepts of aging?

- continuity & development
- gerotranscendence

What are the psychological theories of aging?

wear & tear theory

as time goes by, repeated use and abuse of the body's tissues cause it to be unable to repair all the damage

stochastic

result of random cell damage, leading to physical change

gerotranscendence

- shift in perspective with age, moves from materialistic & national view to a more cosmic & transcendence one
- increases overall life satisfaction

Delirium

- acutely disturbed state of mind that occurs in fever, intoxication, & other disorders
- characterized by restlessness, illusions, & incoherent thoughts/speech
- confusion

Dementia

- chronic mental processing disorder caused by brain disease or injury & marked by memory disorders, personality changes, & impaired reasoning
- intellectual impairment

Depression

mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life

frail

syndrome that describes a heightened state of vulnerability for developmentally adverse health outcomes

- Low level of physical activity
- Muscle weakness
- Slowed performance
- Fatigue & poor endurance
- Thin skinned

What are the five criteria for determining if a patient is frail?

sleep

condition of body & mind that typically occurs for several hours every night, which the nervous system is relatively inactive, eyes are closed, postural muscles relaxed, & consciousness is suspended

false
sleep is a cyclically occurring state of decreased motor activity & perception

True/False: Sleep is a randomly occurring state of increased motor activity & perception

20-30%

During sleep, body function slows ____ - ____ % to conserve energy

rest

- condition which the body is inactive or engaging in mild activity, after which one feels refreshed
- person is calm, at ease, free of anxiety & stress

true
resting doesn't guarantee a person will feel refreshed

True/False: Rest doesn't guarantee that a person will feel refreshed

- affects almost every body tissue
- important regulator of energy metabolism
- may improve learning & adaptation
- reduces stress & adaptation
- decreases energy output to allow the body to rest

What are the functions of sleep?

Circadian rhythms

- biorhythm based on the day-night pattern in a 24 hour cycle
- regulated by a cluster of cells in the hypothalamus
- affected by light, temperature, social activity, work routines

Biorhythm

biological clock" controlled within the body & syncs with environmental factors

- Increases mental performance
- Improves learning
- Helps the storage of long-term memory
- Restores energy
- Improves ability to cope
- Strengthens the immune system

What are the benefits of sleep?

16 hours

How many hours of sleep are required for neonates?

15 hours

How many hours of sleep are required for infants?

12 hours

How many hours of sleep are required for toddlers and preschoolers?

9-10 hours

How many hours of sleep are required for school age children?

7.5 hours

How many hours of sleep are required for adolescents?

6 - 8.5 hours

How many hours of sleep are required for young adults?

NREM

- restful phase of sleep where physical function is slow; AKA. "slow wave sleep" & is characterized by delta waves
- 3 stages, each one deeper than the one preceding it

NREM sleep

During ______ sleep, the parasympathetic branch of the autonomic nervous system becomes progressively more dominate

REM sleep

- phase that occurs in intervals through the night; brain becomes increasingly active & brain waves resemble those of a person that is fully awake
- more spontaneous awakenings happen in this stage

memory & learning

Loss of REM sleep impairs _______ & __________

berlin questionnaire

test that assesses a pt's risk for OSA (obstructive sleep apnea)

epworth sleepiness scale

test that assesses daytime sleepiness

pittsburgh sleep quality index

assesses sleep quality & patterns over a 1 month period

polysomnogram

test that involves the use of electroencephalography (EOG) to monitor the stages of sleep & wakefulness during nighttime

Insomnia

- inability to fall or remain asleep or go back to sleep
- clinically diagnosed when it occurs 3+ times per week and for at least 3 months

- side effect of meds (steroids, central adrenergic blockers, bronchodilators)
- poor sleep hygiene (watching TV in bed, phone nearby, having caffeine before bed)

What two things can contribute to insomnia?

Sleep-wake schedule (circadian) disorder

abnormality in sleep/wake times
i.e.) jet lag, night shift workers, working rotating shifts

Restless leg syndrome (RLS)

uncontrollable movement of legs during sleep

Sleep deprivation

caused by emotional stress, medications, environmental disturbances

Hypersomnia

- excessive sleeping, particularly during the day
- can also be a symptom of depression

- sleep apnea
- narcolepsy
- snoring

What are the three common causes of hypersomnia?

Sleep apnea

- periodic interruption of breathing during sleep
- leads to excessive daytime sleepiness

Narcolepsy

- chronic disorder caused by the brain's inability to regulate sleep-wake cycles normally
- sudden, uncontrollable urge to sleep

Cataplexy

sudden loss of muscle tone usually triggered by an emotional event

Parasomnias

patterns of waking behavior that appears during sleep

- somnambulism
- sleep talking
- bruxism
- night terrors
- nightmares
- nocturnal enuresis

What are the 6 types of parasomnias?

somnambulism

sleepwalking

bruxism

grinding & clenching of the teeth

nocturnal enuresis

bedwetting while asleep

- use sleep assessment tools
- assess normal sleep patterns, sleep rituals, nightmares
- ask their perception of sleep
- check medications
- assess for insomnia, circadian disturbances, restless leg syndrome (RLS)

What sleep assessments can you make for a patient?

- please describe the nature of your sleep problem
- do you wake up during the night?
- can you rate the quality of your sleep last night?
- please describe your bedtime routine

What are some subjective questions you can ask the patient about their sleep patterns?

o Disturbed sleep pattern
o Anxiety
o Ineffective breathing pattern
o Acute confusion
o Compromised family coping
o Ineffective coping
o Insomnia
o Fatigue
o Sleep deprivation
o Readiness for enhanced sleep

What are some nursing diagnoses used for impaired sleep?

o Promote comfort
o Promote relaxation
o Maintain patient safety
o Administer & educate about medication
o Cluster/schedule nursing care to avoid interrupting sleep
o Teach about sleep hygiene
o Offer foods that help promote sleep - CARBS!

What are some interventions a nurse can use for a patient with difficulty sleeping?

EEG (electroencephalogram)

measures activity in the cerebral cortex; affects our overall level of functioning

Dyssomnia

- difficulty falling or staying asleep
- includes insomnia, sleep-wake schedule (circadian) disorders, sleep apnea, restless leg syndrome (RLS), hypersomnia, & narcolepsy

- skin integrity
- pressure ulcers
- wounds
- incisions
- characteristics
- temperature
- moisture
- texture
- edema

What are you looking for during an integumentary assessment?

normal variant (lesions)

What type of lesions consist of milia, nevi, skin tags, & striae?

primary (lesions)

What type of lesions result from disease or local irritation?

secondary (lesions)

What type of lesions develop from a primary lesion?

15%

Deep tissue (pressure) injuries affect what percentage of hospitalized patients?

pressure ulcers / deep tissue injuries
AKA. pressure sore, decubitus injury, bed sore

caused by unrelieved pressure to an area

- immobility
- impaired sensation
- malnourishmnet
- aging
- fever

What are some intrinsic factors for developing pressure ulcers?

- friction
- shearing
- exposure to moisture

What are some extrinsic factors for developing pressure ulcers?

a) arterial
arterial wounds are most often on the foot, in between/on tips of the toes, & around the lateral malleolus (outer ankle)
venous wounds usually develop on the inner leg

What type of wound typically develops on the foot, toes, & outer ankle?
a) arterial
b) venous

b) venous
arterial wounds are round & deep with a "punched out" shape, and comes in many sizes
*note: arterial wounds may appear shallow in the early stages
venous wounds are often large & shallow

What type of wound is large and shallow?
a) arterial
b) venous

a) arterial
arterial wounds have well-defined edges
venous wounds have irregular edges that may slope

What type of wounds have well-defined edges?
a) arterial
b) venous

b) venous
the skin around arterial wounds is pale with non-granulating tissue
the skin around venous wounds is a ruddy red color with granulating tissue

What type of wound is a ruddy red color with granulating tissue?
a) arterial
b) venous

a) arterial
arterial wounds are often yellow, brown, or black in color
venous wounds may have discoloration with yellow slough & a foul odor

What type of would is often yellow, brown, or black in color?

b) venous
the skin around arterial wounds is thin, smooth, taut, cool to the touch, & dry
the skin around venous wounds is shiny, scaly, & warm to the touch

What type of wound causes the surrounding skin to be shiny, scaly, & warm to the touch?

a) arterial
arterial wounds are often dry with very minimal drainage
venous wounds have lots of exudate, making them appear "wet

What type of wound is often dry with minimal drainage?
a) arterial
b) venous

True

True/False: Tunneling is common with venous wounds

a) arterial
arterial wounds are described as very painful
venous wounds are described as dull & aching

What type of wound is described as very painful?
a) arterial
b) venous

- location
- size
- appearance
- drainage

What do you want to look at when assessing wounds?

serous

drainage that is clear, watery plasma

purulent

drainage that is thick and can be green, yellow, tan, or brown in color

serosanguineous

drainage that is pale, pink, & watery; a mixture of clear & red fluid

sanguineous

drainage that is bright red & indicates active bleeding

- size
- shape
- symmetry
- pattern
- color
- distribution
- texture
- surface relationship
- exudate
- tenderness
- pain
- itching
- location

What are some characteristics of pressure wounds?

Stage 1

What stage is the shown pressure injury?

stage 1 pressure injury

intact skin with non-blanchable redness

stage 2

What stage is the shown pressure injury?

stage 2 pressure injury

partial-thickness skin loss involving the epidermis, dermis, or both

stage 3

What stage is the shown pressure injury?

stage 3 pressure injury

full-thickness tissue loss with visible fat

stage 4

What stage is the shown pressure injury?

stage 4 pressure injury

full-thickness tissue loss with exposed bone, muscle, or tendon

6.9 - 8.0 g/dL

What is the normal range for total protein?

12 - 42 mg/dL

What is the normal range for prealbumin?

prealbumin

lab test that fluctuates daily as a marker of nutritional status

3.2 - 4.8 g/dL

What is a normal albumin level?

albumin

lab test that's good for a long-term view of nutritional status; synthesized in the liver & constitutes 60% of body's total protein

malabsorption, malnutrition

A low albumin level can indicate ____________ or ___________

hematocrit & hemoglobin

What is an H&H lab?

Male: 42-52%
Female: 37-47%

What is the normal range for hematocrit?

hematocrit

lab test that indicates how much of your blood is made of RBCs

Male: 14-18 g/dL
Female: 12-16 g/dL

What is the normal range for hemoglobin?

hemoglobin

lab test that determines the number of oxygenated RBCs

5,000 - 10,000/mm3

What is the normal range for WBCs?

WBCs

lab test that indicates infection when elevated

CRP (c-reactive protein)

lab test that indicates arterial inflammation

< or = to 10 mg/L

What is the normal range for CRP?

necrosis

death of tissue

Eschar

tan, black, or brown leathery necrotic tissue

Ischemia

inadequate blood supply to an organ or part of the body

Partial-thickness

- confined to the skin, the dermis & epidermis
- heals by regeneration

Full-thickness

- involving the dermis, epidermis, subcutaneous tissue, & possibly muscle and/or bone
- requires connective tissue repair

Maceration

softening of the skin